Healthcare Provider Details

I. General information

NPI: 1720060247
Provider Name (Legal Business Name): DR. THOMAS KEVIN LACKEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3804 RAINBOW DR
RAINBOW CITY AL
35906
US

IV. Provider business mailing address

3804 RAINBOW DR
RAINBOW CITY AL
35906-3051
US

V. Phone/Fax

Practice location:
  • Phone: 256-952-2200
  • Fax: 256-952-2202
Mailing address:
  • Phone: 256-952-2200
  • Fax: 256-952-2202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number21928
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: